Anna O. was born in the years 1858 or 1859 in Vienna.

Although the predominant society of

Vienna at that time was highly cultured, her family was strictly confined, owing to her family’s religious

doctrines. One can imagine that Anna must have grown up in such a setting feeling torn in two

directions; on the one hand, wanting to be part of the society at large partaking of fine food and

indulging in theater and yet, on the other hand, feeling bound, perhaps inhibited, by her family setting

which was more restrictive and didn’t allow her to fully assimilate into the attractive culture that

surrounded her.

To further understand this inner conflict, one must consider that the political time period was

one in which a well brought up daughter dare not express criticism and anger directly toward a parent,

and thus, she surely must have felt compelled to remain loyal to her father’s religious doctrines. Thus,

she naturally developed an inner conflict where she identified with the culture around her and longed

for it, and yet felt inhibited to do so because of her father’s religion, which she dare not overtly criticize.

In light of this inner-conflict, one begins to appreciate the etiology of her “self-induced”

hypnosis which later manifests itself when she began recounting lengthy stories in a highly dramatic

tone of voice. Simply put, Anna was indulging and attempting to partake of the world of theater that

she so long to experience outside the confines of her family. This self-induced hypnosis was nothing

more than her “big performance.” Anna herself actually articulates this, as she recalls, “I often make up

fairy tales. I call it my private theater. When I did household chores, it made the work less drudgery.”

Her varying mental states can thus be attributed to the varying manifestation of these divergent parts of

her, which she never reconciled. Having not reconciled these two parts of her, each part has become

quite extreme and polarized. This is significant to understand the symptoms and timing that Anna first

seeks help.
 Anna only comes in for consultation at the age of 22 because of the onset of bizarre and

debilitating abreaction to the news that her father Sigmund has fallen seriously ill. We don’t have a

clear picture of the family when she was younger. However, when she presents herself at this time, it is

clear that she is deeply enmeshed with her father. This relationship is facilitated by his pampering her

and equally his infatuation for her.

In fact, the very fact that she is suffering mentally and physically from the news of her father

falling ill is in itself indicative of the unhealthy enmeshment. This is expressed in the very symptoms she

presents such as paralysis and lack of feeling in her right arm. Both symptoms indicate that she feels

that as her father dies, a part of her is also dying.

However, there are several other presenting symptoms that I suspect create a distinct

constellation of symptoms, meaning that they are expressing something else aside from her

enmeshment. She is gradually losing her ability to talk. It starts with a nervous cough that only disrupts

her speech, but then progresses to her ability to only speak English and finally she becomes mute.

I suspect that these two distinct constellations of symptoms correlate to Anna’s unresolved

inner conflict between being compelled to be a good daughter who adheres to her father’s direction and

the consequential inhibition she experiences preventing her from partaking of the cultured society

surrounding her. As her father falls ill and nears death, the part of her which is compelled to conform to

her father’s direction and has enmeshed with her father feels the imminent loss as her own, which

explains the paralysis and numbing of arm. On the other hand, the part of her which wishes to defy her

father’s direction and yearns to express itself becomes desperate at its last chance. Therefore, as she

represses it in exchange for an enmeshment that finds physical manifestation, her body literally takes on

the burden of muting her as well.

 Anna’s mother, on the other hand, is at quite a distance from both Anna and Sigmund. It would

seem that Anna served to be the third point of a triangle, wherein she and her father join in an alliance

and the mother is disengaged, at least emotionally. The Mother and Sigmund are more disengaged but

not in open conflict as where Mother and Anna are more conflictual.

It will be top priority to restore the marital subsystem in order to reestablish boundaries in the

family, namely helping Anna and her father secure healthier boundaries. It is important to understand

that the nature of this triangle in cyclical and thus, self perpetuating. To fully grasp this, it is helpful to

consider how the triangle began.

When Anna was only seven years old, her older sister Henrietta died at the age of 18, which was

about 10 or 11 years following the death of Flora, Anna’s sister who died at the age of two. It is

interesting to note that Anna’s mother was wed at that very age that Henrietta died, and so Henrietta’s

death came at a time when she was probably already expected to be setup in marriage. Perhaps with

the death of their oldest daughter, the O family was also devastated by the loss of the dream of

marrying off their daughter. As such, I wonder if they ever fully mourned the death Henrietta on both

levels; that it, the loss of their daughter and the loss of their dream to see her wed. Furthermore, the

disengagement between Sigmund and Mother make me wonder if they fully grieved the loss of their

children, and more specifically if they dealt with it differently. If each parent experiences the grievance

differently, that could make each one feel isolated from the other and create the current schism that

divides them now. It would seem after initial consultation that the O. family doesn’t speak much about

their emotions especially about the deaths of their children.

This sheds light on the nature of the triangle in the O. family: Father has become overly

attached to Anna. O (perhaps because he never mourned the loss of Henrietta and seeks to hold on to

the daughter he has left). Mother on the other hand becomes distant from Anna (perhaps because she
never mourned Henrietta’s death, and is afraid to re-experience the loss of a beloved daughter). This

creates a schism between Mother and Father both because they haven’t mourned the loss of Henrietta

together and because they treat Anna quite differently.

As father becomes closer to Anna, Mother pulls away from both, so as she pulls away from him

he further turns to Anna for companionship. (Furthermore, their opposite approaches in connecting to

Anna may have an element of complimentarity). Thus, the triangle is cyclical in nature.

We have noted Anna’s internal conflict of two divergent parts of her not reconciled and having

thus become very extreme. Although individual therapy will be helpful for her to facilitate the process

of reconciling her divergent internal parts, nonetheless, initially family therapy will be most beneficial

because, as noted above, her enmeshment with her father is what exacerbates her muting of self and

feelings of inhibition. Therefore, after the therapist attenuates the extremity of the enmeshment

between Anna and her father, Anna will be in a better position to benefit from individual therapy.

As mentioned previously, Anna is torn between wanting to indulge in the highly cultured society

around her and yet inhibited because she has to conform to her father’s religious doctrines. When Anna

grew older she wants very much to pursue an education and yet she is unable to do so owing to the fact

that women in this time period were simply not allowed to matriculate in most universities. However,

Anna, having developed this attitude of being inhibited by having to conform to her father’s

confinement, believes that the reason she is inhibited in this is once again owing to her father’s

confinement of her. This is a cognitive distortion of which she is probably not aware. A simple checking-

in with the father and his religious doctrines may be enough to help her or having her consider

alternative thoughts, she may quickly realize the cognitive distortion.

In summary, the therapist conceptualizes Anna’s symptoms as the expression of her own inner

conflict which is exacerbated by her being enmeshed with her father. The enmeshment of Anna with
her father is an unhealthy boundary that is part of a triangle that keeps apart Mother and Father. The

most immediate objective of therapy is to restore healthy boundaries and re-enforce the marital

subsystem and therefore structural techniques will be most effective to this end. Additionally, since the

distance of Mother and Father is believed to have started when they didn’t mourn together the loss of

their deceased children, experiential therapy is the most appropriate modality of therapy to unite

Mother and Father. However, there is probably the need for a lot of cognitive interventions along the

way just to bring Mother and Father to be on the same page about how they feel about each other.
 The O. family enters room and Father and Anna sit next to each other rather close on the couch.
There’s enough room for Mother to join them, but she sits on the arm chair next to the couch.

Therapist: Where do you want to start?

Mother: Anna… She, well she is just hysterical recently. You wouldn’t believe the way she acts and the
things she says sometimes. Please, doctor, you must help her or tell us what to do!

Therapist: Hmm… It sounds like it’s very serious, help me to understand it better. What exactly is she
doing and what would you like to see her change? Actually, before you answer I’d like to hear what
Sigmund has to say about this.

(Turns to father)

Father: (He smiles at Anna) Anna O. Anna O. Ohhhh Anna! Hahaha, she’s just a little feisty sometimes.
I’m certainly concerned for her as well, but I do think she is quite a special girl and shouldn’t be deemed
possessed. Look at how beautiful she is. (Anna looks at her father and smiles).

Mother: What is so beautiful about a girl who acts out as she does? What is feisty about a girl who at
unpredictable times becomes paralyzed or only speaks English?! She needs help. Maybe put her back in
the hospital!

(Therapist allows the enactment)

Father: Oh dear, I don’t think she should leave home for so long again. What would she do without me,
what would I do without her? (To Anna): you wouldn’t want to go away again would you?

Anna: No father, especially if it would make you so sad, when you’re sick like this.

Therapist: Ok, I don’t want to discuss that option just yet. First, I’m gonna ask that you to stand up. Not
just you, everybody.

Everybody stands up, and the therapist directs them such that the mother and father are on the couch
next to each other and Anna is also on the couch. The therapist looks at the new picture and says, “No,
we’re not there yet.” He then guides Anna to leaving the couch and sitting on the armchair by herself.
“Yes, that’s it. Much better.” (Break-up coalitions and re-establishing hierarchy, specifically marital
subsystem)

Mother: What’s the purpose of this?

Father: Yes, why are you doing this?

Therapist: Is there something the matter?

Both mother and father seem uncomfortable.

Therapist: Well, I’ll be! It seems I’ve actually succeeded in getting Mother and Father on the same page
about something… Both of you don’t want to sit next to each other! (Intensity)

Father: What’s that supposed to mean?

Therapist: You know better than I. Why don’t you want to sit next to your wife without Anna?

Father: I don’t think she loves Anna, in fact I don’t think she loves me.

Therapist: You ever tell her that?

Father: no.

Therapist: Try… Start off, “I feel…” (I feel statements- Experiential)

Father (to mother): I feel you don’t love me or Anna and that’s why you are trying to send her to a
hospital away from us.

Mother: Why wouldn’t I love her?! I’m her mother!

Therapist: First, can you repeat back to Sigmund what he just told you? (mirroring)

Mother: You think I don’t love you or Anna.

Therapist: Is it true? (Checking-in on cognitive distortion)

Mother: NO!

Father: But then, why don’t you show love to her the way I do?

Mother: I can’t.
Father: Why “can’t” you?

Mother: I don’t want to lose her?

Father: That makes no sense!

Therapist: Sigmund, before you judge its sensibility, can you repeat back to Mother what she said?
(Teaching mirroring)

Father: She doesn’t want to love Anna because she can’t.

Therapist: Is that what you said, Mother? (Facilitating their ability to communicate more clearly and
directly)

Mother: No. I said, I don’t want to lose her and so I can’t love her the way you can.

Therapist: Sigmund, repeat it to her.

Father: You feel you can’t love her the way I can, because you don’t want to lose her.

Mother: Right. Well, I guess I’m afraid to love her because I’m afraid to lose her.

Father: So, you’re scared.

Mother: Yes. And you know what? I don’t know why you aren’t scared, how you can be so close to her.

Therapist: Mother, I noticed you tighten up a little and your voice crack when you said that. What’s that
like for you when you think he’s not scared like you? (slowing down and breaking down emotions in
order to help express primary emotions)

Mother: Lonely.

Therapist: Can you tell him. And again, try saying, “When I see you aren’t afraid to love Anna the way I
am, I feel…

Mother (to Father): When I see you aren’t afraid to love Anna the way that I am, I feel lonely. (Begins to
cry)

Father: I didn’t know. I thought you didn’t love us… I didn’t know.